Wound Assessment

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Original Editor - Lucinda hampton

Top Contributors - Lucinda hampton, Abbey Wright and Kim Jackson  

Introduction

A wound is damaged or disruption to the skin and, before treatment, the exact cause, location, and type of wound must be assessed to provide appropriate treatment

Wound healing: complex physiological process occurring after an injury in the cells and tissues of our bodies to restore function of the tissue.

The healing process is affected by the

• Severity of the wound
• Location,
• Extent of injury
• External and internal factors that will either inhibit or promote wound healing.

A health care provider must understand how to assess a wound, assess external and internal factors, and determine treatment to optimize the healing process.

Why Assess?

We perform wound assessment as a means for determining the appropriate treatment for an extremely diverse grouping of disease processes. Each of the underlying etiologies of the given wound must be identified and treated as if it were its own disease (not a blanket classification of "wound").

The initial assessment should begin with the following:

• How: How was the wound created and, if chronic, why is it still open? (underlying etiology)
• Where: Where on the body is it located? Is it in an area which is difficult to offload, or to keep clean? Is it in an area of high skin tension? Is it near any vital structures such as a major artery?
• When: How long has this wound been present? (eg., chronic or acute)
• What: What anatomy does it extend? (e.g., epidermis, dermis, subcutaneous tissue, fascia, muscle, tendon, bone, arteries, nerves)
• What: What comorbidities or social factors does the patient have which might affect which might affect their ability to heal the wound?
• Is it life threatening?

The above factors significantly affect the treatment plan moving forward. While there are many excellent biologics, skin grafts, and other options available, without the appropriate understanding of the nature of the wound the chances of healing decline significantly.

Areas Of Concern

While some wounds are simple, the majority of wounds we encounter are caused by or complicated by some other issue. Eg:

• A chronic wound will have a different makeup than that of an acute wound, requiring conversion for healing.
• An underlying infection will prevent wound healing even if the infection is subacute.
• A damaged or constricted arterial supply will prevent appropriate blood flow to the wound.
• A damaged venous supply will cause venous stasis.
• Physical pressure on chronic ulceration will cause repeated damage, preventing healing.

Wound Assessment

Wound assessment: Should include a comprehensive patient history, etiology of the wound, condition of the wound bed and periwound area including the amount, colour, and consistency of exudate as well as signs of infection.

• Identify the location of the wound
• Determine the cause of the wound
• Determine the stage of the wound
  • Stage I: Superficial involving only the epidermal layer
  • Stage II: Partial-thickness affects the epidermis, and may extend into the dermis
  • Stage III: Full-thickness extends through the dermis and into the adipose tissues
  • Stage IV: Full-thickness extends through the dermis, and adipose exposing muscle or bone
• Evaluate and measure the depth, length, and width of the wound
• Measure the amount of undermining and tunneling
• Evaluate the wound bed
• Assess for presents, type, and amount of exudate:
  • Serous, serosanguineous, sanguineous, or purulent
  • Minimal, light, moderate, or heavy
• Access surrounding skin tissue
• Assess wound margins for tunneling, rolled, undermining, fibrotic changes, and if unattached
• Evaluate for signs and symptoms of infect - warm, pain, odor, delayed healing
• Assess pain

Patient Assessment: A holistic assessment of the patient is essential to identify the causative or contributory factors and to highlight issues that could delay wound healing. The following factors must be considered when choosing an appropriate plan of care.

• Age
• Medication and allergies
• Other diseases such as
  • Diabetes
  • Vascular diseases
  • Immune systems that are compromised
• Nutritional status and fluid intake
• Smoking/alcohol
• Obesity
• Mobility
• Continence
• Pressure sore risk
• Oxygen deficit/anaemia
• Skin sensitivity and integrity

These factors above will either delay or promote the wound healing process. Successful wound healing is dependent on the patient’s ability to heal, not the dressing used.

Most chronic wounds are complex and best managed by an interprofessional team that includes a wound care nurse, general and vascular surgeon, hyperbaric specialist, infectious disease consultant, dietitian, and physical therapist. The key is to first find out the cause of wound breakdown. Without resolving the primary cause, wounds cannot heal.

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